Healthcare Provider Details

I. General information

NPI: 1326624016
Provider Name (Legal Business Name): PATRICK THOMAS PANOS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11820 S MAPLE RIDGE CIR
SANDY UT
84094-7332
US

IV. Provider business mailing address

11820 S MAPLE RIDGE CIR
SANDY UT
84094-7332
US

V. Phone/Fax

Practice location:
  • Phone: 801-671-5226
  • Fax:
Mailing address:
  • Phone: 801-671-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number116155-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: